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Morganroth J, Zuroff L, Guidon AC, Liu GT, Bird SJ, Singhal S, Wolfe GI, Hamedani AG. Trends and Disparities in the Utilization of Thymectomy for Myasthenia Gravis in the United States. Neurol Clin Pract 2024; 14:e200335. [PMID: 38919930 PMCID: PMC11194790 DOI: 10.1212/cpj.0000000000200335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/15/2024] [Indexed: 06/27/2024]
Abstract
Background and Objectives In 2016, a randomized controlled trial demonstrated the clinical efficacy of trans-sternal thymectomy for patients with non-thymomatous myasthenia gravis (MG). Whether large-scale changes occurred in clinical practice after this trial is unknown. Methods We performed a retrospective longitudinal cross-sectional analysis using National Inpatient Sample (NIS) data from 2012 to 2019. Our study included hospitalized adults at least 18 years of age diagnosed with MG without an associated thymoma. We used joinpoint regression to analyze annual trends in thymectomy volume and surgical approach (minimally invasive vs trans-sternal) from 2012 to 2019. Using logistic regression models, we examined patient and hospital-level factors that may have influenced whether thymectomy was performed, such as age, sex, race, insurance payor, hospital size and teaching status, and Elixhauser Comorbidity Index. Sampling weights were applied to account for the complex survey design of NIS. Results The total number of thymectomy procedures increased by 69.8% per year (95% CI 40.1-105.8) between 2012 and 2019. Trans-sternal thymectomies increased by 62.8% per year (95% CI 35.8-95.2) and minimally invasive thymectomies by 83.7% per year (95% CI 38.1-144.3). Thymectomies were significantly more likely to occur in 2017-2019 compared with 2012-2016 (OR 1.93, 95% CI 1.62-2.31). In a multivariable regression model, several factors decreased the odds of patients with MG having a thymectomy: older age, Black race (OR 0.62, 95% CI 0.49-0.77), female (OR 0.73, 95% CI 0.63-0.86), and higher Elixhauser Comorbidity Index. Patients in medium (OR 1.82, 95% CI 1.30-2.55) or large (OR 2.81, 95% CI 2.07-3.82) size and urban teaching hospitals (OR 6.09, 95% CI 2.65-13.97) were more likely to undergo thymectomy. Discussion Thymectomy is being performed more frequently for non-thymomatous MG, especially after 2016 after publication of a positive phase III clinical trial. There are several disparities in thymectomy utilization that warrant further attention.
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Affiliation(s)
- Jennifer Morganroth
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Leah Zuroff
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Amanda C Guidon
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Grant T Liu
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shawn J Bird
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sunil Singhal
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gil I Wolfe
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ali G Hamedani
- Department of Neurology (JM, LZ, GTL, SJB, AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Division of Neuromuscular Medicine (ACG), Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston; Department of Ophthalmology (GTL, AGH); Division of Thoracic Surgery (SS), Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Neurology (GIW), Jacobs School of Medicine and Biomedical Sciences, State University at Buffalo/SUNY, NY; and Department of Biostatistics, Epidemiology, and Informatics (AGH), Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Lee JH, Hwang J, Park TH, Gu BM, Jung Y, Yi E, Lee S, Hwang SY, Chung JH, Kim HK. Subxiphoid Single-Port Robotic Thymectomy Using the Single-Port Robotic System versus VATS: A Multi-Institutional, Retrospective, and Propensity Score-Matched Study. Cancers (Basel) 2024; 16:2856. [PMID: 39199627 PMCID: PMC11353098 DOI: 10.3390/cancers16162856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 08/09/2024] [Accepted: 08/14/2024] [Indexed: 09/01/2024] Open
Abstract
Subxiphoid thymectomy is a novel alternative to the transthoracic approach and sternotomy, with potential benefits, such as reduced postoperative pain and faster recovery. We previously reported the initial experience with subxiphoid single-port robotic-assisted thoracic surgery (SRATS) thymectomy using the single-port robotic system (SPS). However, the efficacy of this technique remains unknown. Thus, this study examined the multi-institutional experience with SRATS thymectomy and compared the perioperative outcomes of this technique to those of subxiphoid single-port video-assisted thoracic surgery (SVATS) thymectomy. The data of patients who underwent subxiphoid SRATS and SVATS thymectomy, performed by three thoracic surgeons at three institutions between September 2018 and May 2024, were retrospectively collected. In total, 110 patients were included, with 85 and 25 undergoing SRATS and SVATS thymectomy, respectively. After propensity score matching, 25 patients were included in each group. The SRATS group was associated with a lower conversion rate to multi-port surgery (0% vs. 20%, p = 0.05), shorter chest tube drainage duration (1.32 ± 0.75 vs. 2.00 ± 1.29 days, p = 0.003), and a shorter postoperative hospital stay (2.52 ± 1.00 vs. 5.08 ± 5.20 days, p = 0.003). Subxiphoid SRATS thymectomy using the SPS is feasible and is a good alternative to conventional thymectomy. Further studies are necessary to confirm its benefits.
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Affiliation(s)
- Jun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (J.H.L.); (T.H.P.); (B.M.G.)
| | - Jinwook Hwang
- Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University College of Medicine, Ansan 15355, Republic of Korea;
| | - Tae Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (J.H.L.); (T.H.P.); (B.M.G.)
| | - Byung Mo Gu
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (J.H.L.); (T.H.P.); (B.M.G.)
| | - Younggi Jung
- Department of Thoracic and Cardiovascular Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (Y.J.); (E.Y.); (S.L.)
| | - Eunjue Yi
- Department of Thoracic and Cardiovascular Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (Y.J.); (E.Y.); (S.L.)
| | - Sungho Lee
- Department of Thoracic and Cardiovascular Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (Y.J.); (E.Y.); (S.L.)
| | - Soon Young Hwang
- Department of Biostatistics, Korea University College of Medicine, Seoul 02841, Republic of Korea;
| | - Jae ho Chung
- Department of Thoracic and Cardiovascular Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (Y.J.); (E.Y.); (S.L.)
| | - Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea; (J.H.L.); (T.H.P.); (B.M.G.)
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Dang J, Sun S, Wu Z, Shan Y, Zhang H. Meta-analysis of clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors. World J Surg Oncol 2024; 22:70. [PMID: 38413953 PMCID: PMC10900664 DOI: 10.1186/s12957-024-03325-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/23/2024] [Indexed: 02/29/2024] Open
Abstract
OBJECTIVE Comparing the clinical efficacy of thoracoscopy and robotic surgery in the treatment of mediastinal tumors using meta-analysis. METHODS Computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science databases for literature comparing the clinical effects of video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) in treating mediastinal tumors, with the retrieval time limit from the establishment of the database to September 2023. Two evaluators independently screened the literature, extracted data, and assessed the risk of bias. Meta-analysis was performed using RevMan 5.4. RESULTS A total of 19 articles were included, with a total of 3517 patients. The results of the Meta-analysis showed that the RATS group had less intraoperative bleeding [MD = - 5.20, 95%CI (- 9.28, - 1.12), P = 0.01], lower rate of conversion to thoracotomy [OR = 0.41, 95%CI (0.23, 0.72), P = 0.002], lower rate of total postoperative complications [OR = 0.57, 95%CI (0.34, 0.95), P = 0.03], shorter postoperative drainage time [MD = - 0.72, 95%CI (- 1.13, - 0.32), P = 0.0004], and shorter postoperative hospital stay [MD = - 0.90, 95%CI (- 1.16, - 0.65), P < 0.001], in comparison with the VATS group. There was an insignificant difference between the two groups in terms of tumor size [MD = - 0.02, 95%CI (- 0.33, 0.30), P = 0.91] and operation time [MD = 0.17, 95%CI (- 7.61, 7.94), P = 0.97]. However, in regards to hospitalization costs [MD = 2634.75, 95%CI (991.62, 4277.88), P = 0.002], the RATS group was more expensive than the VATS group. CONCLUSION Robot-assisted mediastinal tumor resection surgery has more advantages in terms of intraoperative bleeding, conversion to thoracotomy rate, total postoperative complication rate, postoperative drainage time, and postoperative hospital stay, in comparison with thoracoscopic-assisted mediastinal tumor resection surgery. There is an insignificant difference in tumor size and operation time between the two surgeries. However, robot-assisted mediastinal tumor resection surgery increases hospitalization costs.
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Affiliation(s)
| | - Shize Sun
- Wuwei Liangzhou Hospital, Gansu, China
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Chao YK, Lee JY, Lu HI, Tseng YL, Lee JM, Huang WC. Robot-assisted surgery outperforms video-assisted thoracoscopic surgery for anterior mediastinal disease: a multi-institutional study. J Robot Surg 2024; 18:21. [PMID: 38217569 DOI: 10.1007/s11701-023-01745-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/10/2023] [Indexed: 01/15/2024]
Abstract
Anterior mediastinal procedures are increasingly being performed using robot-assisted thoracic surgery (RATS) or video-assisted thoracoscopic surgery (VATS). While both approaches have shown superior outcomes compared to open surgery, their comparative benefits are not as distinct. The aim of this retrospective study was to bridge this knowledge gap using a multicenter dataset. Patients who underwent elective minimally invasive surgery for anterior mediastinal disease between 2015 and 2022 were deemed eligible. The study participants were grouped based on whether a robot was used or not, and perioperative outcomes were compared. To mitigate selection bias, inverse probability of treatment weighting (ITPW) was applied using the propensity score. The final analysis included 312 patients (RATS = 120; VATS = 192). Following the application of IPTW, RATS was found to be associated with a longer operating time (215.3 versus 139.31 min, P < 0.001), fewer days with a chest tube (1.96 versus 2.61 days, P = 0.047), and a shorter hospital stay (3.03 versus 3.91 days, P = 0.041) compared to VATS. Subgroup analyses indicated that the benefit of RATS in reducing the length of hospital stay was particularly pronounced in patients with tumors larger than 6 cm (mean difference [MD] = - 2.28 days, P = 0.033), those diagnosed with myasthenia gravis (MD = - 3.84 days, P = 0.002), and those who underwent a trans-subxiphoid surgical approach (MD = - 0.81 days, P = 0.04). Both VATS and RATS are safe and effective approaches for treating anterior mediastinal disease. However, RATS holds distinct advantages over VATS including shorter hospital stays and reduced chest tube drainage periods.
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Affiliation(s)
- Yin-Kai Chao
- Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, 5 Fuxing Street, Taoyuan, 333, Taiwan.
| | - Jui-Ying Lee
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
| | - Hung-I Lu
- Department of Cardiovascular and Thoracic Surgery, Chang Gung Memorial Hospital-Kaohsiung, Chang Gung University, Kaohsiung, Taiwan
| | - Yau-Lin Tseng
- Division of Thoracic Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Jang-Ming Lee
- Department of Surgery, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Wen-Chien Huang
- Department of Thoracic Surgery, Mackay Memorial Hospital, Taipei, Taiwan
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O'Brien LP, Hannan E, Antao B, Peirce C. Paediatric robotic surgery: a narrative review. J Robot Surg 2023; 17:1171-1179. [PMID: 36645643 PMCID: PMC10374698 DOI: 10.1007/s11701-023-01523-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 01/02/2023] [Indexed: 01/17/2023]
Abstract
The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.
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Affiliation(s)
- Lukas Padraig O'Brien
- Department of Paediatric Surgery, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Enda Hannan
- Department of Colorectal Surgery, University Hospital Limerick, St Nessan's Road, Dooradoyle, Limerick, Co Limerick, Ireland.
| | - Brice Antao
- Department of Paediatric Surgery, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin Peirce
- Department of Colorectal Surgery, University Hospital Limerick, St Nessan's Road, Dooradoyle, Limerick, Co Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
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Tamburini N, D'Urbano F, Bagolini F, Trapella GS, Quarantotto F, Cavallesco G, Maniscalco P. Unilateral Thoracoscopic Thymectomy for Thymoma: Does Side Matter? A Single Institutional Experience. Thorac Cardiovasc Surg 2023; 71:418-424. [PMID: 34521142 DOI: 10.1055/s-0041-1731778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Thoracoscopic thymectomy is increasingly performed for the treatment of early stage thymoma. It is characterized by shorter postoperative hospital stay, decreased intraoperative blood loss, and fewer complications compared with transsternal thymectomy. Unilateral video-assisted thoracic surgery (VATS) thymectomy can be easily performed from either side of the thorax, because thymus is located in the middle of mediastinum. However, the side that provides better outcomes remains controversial. The purpose of this study was to compare the efficacy of right and left approaches in performing unilateral thoracoscopic thymectomy for thymoma. METHODS Consecutive patients affected by thymoma who underwent VATS thymectomy on either side between February 2001 and March 2020 were enrolled in the study. Clinicopathologic, surgical, and oncological outcomes were retrospectively analyzed and compared among the two surgical approaches. RESULTS Unilateral VATS approaches were performed on 29 patients: 12 (41%) on the left side and 17 (59%) on the right side. The mean age was 63.1 ± 11.3 years and the female/male ratio was 1.73:1. The mean operative time and the hospital stay for the left-side VATS and right-side VATS groups were, respectively, 168 ± 49.5 versus 171 ± 47.9 minutes (p = 0.9) and 3 ± 1.03 days versus 3.65 ± 1.93 days (p = 0.7). Postoperative complications occurred in one patient (3%) for left-side VATS group and one patient (3%) for right-side VATS. The 5-year disease-free survival was comparable between two groups (p = 0.74). CONCLUSION Unilateral VATS thymectomy in patients with thymoma can be safely and effectively performed by experienced surgeons in either side of the thorax with equivalent oncological outcomes.
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Affiliation(s)
- Nicola Tamburini
- Section of General and Thoracic Surgery, Department of Morphology, Experimental Medicine and Surgery, Ferrara, Italy
| | - Francesco D'Urbano
- Section of General and Thoracic Surgery, Department of Morphology, Experimental Medicine and Surgery, Ferrara, Italy
| | - Francesco Bagolini
- Section of General and Thoracic Surgery, Department of Morphology, Experimental Medicine and Surgery, Ferrara, Italy
| | - Giulia Salerno Trapella
- Section of General and Thoracic Surgery, Department of Morphology, Experimental Medicine and Surgery, Ferrara, Italy
| | - Francesco Quarantotto
- Section of General and Thoracic Surgery, Department of Morphology, Experimental Medicine and Surgery, Ferrara, Italy
| | - Giorgio Cavallesco
- Section of General and Thoracic Surgery, Department of Morphology, Experimental Medicine and Surgery, Ferrara, Italy
| | - Pio Maniscalco
- Section of General and Thoracic Surgery, Department of Morphology, Experimental Medicine and Surgery, Ferrara, Italy
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Eichhorn M, Rotärmel A, Haag J, Baum P, Winter H. [Robot-assisted Thoracic Surgery: Learning Curve and Cost Analysis in a German High-Volume Centre]. Zentralbl Chir 2023; 148:S26-S32. [PMID: 36108654 DOI: 10.1055/a-1921-9058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Robot-assisted thoracic surgery (RATS) is a rapidly evolving surgical technique in Europe. The aim of the study was to analyse the learning curve and safety during the establishment of a RATS-program at a high-volume thoracic surgery centre and to quantify the costs of the surgical procedure in Germany. Within a period of 33 months, 255 patients were prospectively enrolled in the study and all perioperative process times and complications were recorded. Mediastinal procedures were performed in 46%, anatomical lung resections in 38%, wedge resections in 7% and diaphragm plications in 6% of patients. The mean operating time was 130 min and the total length of stay was 7 days. The conversion rate was 3.2% and 30-day mortality 1.2%. Mean costs for surgical consumables per intervention amounted to 2,039 €; the average reimbursement was 9,568 €. In summary, RATS can be safely established, performed and trained with low complication rates and acceptable costs for consumables.
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Affiliation(s)
- Martin Eichhorn
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Deutsches Zentrum für Lungenforschung (DZL), Translational Lung Research Center Heidelberg, Heidelberg, Deutschland
| | - André Rotärmel
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Johannes Haag
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Philip Baum
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Hauke Winter
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Deutsches Zentrum für Lungenforschung (DZL), Translational Lung Research Center Heidelberg, Heidelberg, Deutschland
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Rückert JC, Huang L. [Robot-assisted Mediastinal Surgery]. Zentralbl Chir 2023; 148:S17-S25. [PMID: 36195108 DOI: 10.1055/a-1921-1530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Because of the many important anatomical structures located closely together at very small distances, mediastinal surgery has been traditionally demanding and challenging within thoracic surgery. With their great variability, mediastinal masses in the anterior, middle or posterior mediastinal compartment result in surgical indications with different principle focuses. The technical opportunities of robotic assistance can thereby most effectively support the requirement of precision for all oncological aspects. Anterior mediastinal operations are most often performed, thymectomy being the most common operation. The radicality of thymectomy is of special importance. The worldwide tremendous development of robot-assisted mediastinal surgery confirms its initial and continuous role as a pacemaker for minimally invasive thoracic surgery.
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Affiliation(s)
| | - Luyu Huang
- Thoracic Surgery, Charité Universitätsmedizin Berlin, Berlin, Deutschland
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Marcuse F, Hoeijmakers JG, Hochstenbag M, Hamid MA, Keijzers M, Mané-Damas M, Martinez-Martinez P, Verschuuren J, Kuks J, Beekman R, van der Kooi AJ, van Doorn P, van Es M, Maessen JJ, De Baets MH. Outcomes after robotic thymectomy in nonthymomatous versus thymomatous patients with acetylcholine-receptor-antibody-associated myasthenia gravis. Neuromuscul Disord 2023; 33:417-424. [PMID: 37037051 DOI: 10.1016/j.nmd.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/08/2023] [Accepted: 03/15/2023] [Indexed: 03/18/2023]
Abstract
The aim of this study was to investigate the surgical and long-term neurological outcomes of patients with acetylcholine-receptor-antibody-associated myasthenia gravis (AChR-MG) who underwent robotic thymectomy (RATS). We retrospectively analyzed the clinical-pathological data of all patients with AChR-MG who underwent RATS using the DaVinci® Robotic System at the MUMC+ between April 2004 and December 2018. Follow-up data were collected from 60 referring Dutch hospitals. In total, 230 myasthenic patients including 76 patients with a thymoma (33.0%) were enrolled in this study. Mean follow-up time, procedure time and hospitalization were, respectively 65.7 ± 43.1 months, 111±52.5 min and 3.3 ± 2.2 days. Thymomatous patients had significantly more frequently and more severe complications than nonthymomatous patients (18.4% vs. 3.9%, p<0.001). Follow up data was available in 71.7% of the included patients. The Myasthenia Gravis Foundation of America postintervention score showed any kind of improvement of MG-symptoms after RATS in 82.4% of the patients. Complete stable remission (CSR) or pharmacological remission (PR) of MG was observed in 8.4% and 39.4% of the patients, respectively. Mean time till CSR/PR remission after thymectomy was 26.2 ± 29.2 months. No statistical difference was found in remission or improvement in MGFA scale between thymomatous and nonthymomatous patients. RATS is safe and feasible in patients with MG. The majority of the patients (82.4%) improved after thymectomy. CSR and PR were observed in 8.4% and 39.4% of the patients, respectively, with a mean of 26.2 months after thymectomy. Thymomatous patients had more frequently and more severe complications compared to nonthymomatous patients.
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Robotic Mediastinal Surgery. Thorac Surg Clin 2023; 33:89-97. [DOI: 10.1016/j.thorsurg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Rodriguez M, Milla L, Wee JO. The role of minimally invasive surgery in the management of giant mediastinal tumors: a narrative review. MEDIASTINUM (HONG KONG, CHINA) 2022; 6:37. [PMID: 36582972 PMCID: PMC9792823 DOI: 10.21037/med-21-38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/11/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Beyond diagnosis, minimally invasive surgery has traditionally not been considered suitable for large tumors, those invading vital structures or high-risk patients. However, with the improvement of multimodality treatments able to reduce tumor size preoperatively, patient evaluation and selection, perioperative care (including both surgical and anesthesiological techniques) and postoperative management, the indications of minimally invasive surgery, even in giant mediastinal tumors, have increased and will continue to broaden in future years. This review aims to summarize the existing literature regarding the role of minimally invasive surgery in the management of giant mediastinal tumors. We have focused in the role minimally invasive surgery has in diagnosis and treatment of these tumors and we have tried to provide an updated perspective to identify future applications and work-directions. METHODS Data regarding minimally invasive surgery in giant mediastinal tumors are limited, including a proper definition of them. We performed a PubMed search of English and Spanish written studies until August 2021. KEY CONTENT AND FINDINGS There is limited data related to minimally invasive surgery in giant mediastinal tumors and much of the literature review we have performed has yielded isolated case reports, case series with a low number of cases or editorials. Although the role of minimally invasive surgery is well consolidated as a diagnostic approach, adequate patient selection, hospital volume and experience, multidisciplinary discussion of candidates, patient safety and adequate oncological resection remain the most important aspects to be taken into account when considering a minimally invasive approach for a giant mediastinal tumor. CONCLUSIONS With careful and multidisciplinary perioperative planning, minimally invasive surgery has shown to be safe and to provide at least similar outcomes when compared to open approaches in well selected cases. Although data is still limited, improved surgical techniques and available technology will pave the way to increased indications of minimally invasive surgery in giant mediastinal tumors.
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Affiliation(s)
- Maria Rodriguez
- Department of Thoracic Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - Lucia Milla
- Department of Thoracic Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - Jon O. Wee
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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12
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Evaluating the implementation of robotic thoracic surgery on a Veterans Administration Hospital. J Robot Surg 2022; 17:365-374. [PMID: 35670989 PMCID: PMC9170878 DOI: 10.1007/s11701-022-01427-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
Abstract
Robotic thoracic surgery has demonstrated benefits. We aimed to evaluate implementation of a robotic thoracic surgery program on postoperative outcomes at our Veteran’s Administration Medical Center (VAMC). We retrospectively reviewed our VAMC database from 2015 to 2021. Patients who underwent surgery with intention to treat lung nodules were included. Primary outcome was patient length of stay (LOS). Patients were grouped by surgical approach and stratified to before and after adoption of robotic surgery. Univariate comparison of postoperative outcomes was performed using Wilcoxon rank sums and chi-squared tests. Multivariate regression was performed to control for ASA class. P values < 0.05 were considered significant. Outcomes of 108 patients were assessed. 63 operations (58%) occurred before and 45 (42%) after robotic surgery implementation. There were no differences in patient preoperative characteristics. More patients underwent minimally invasive surgery (MIS) in the post-implementation era than pre-implementation (85% vs. 42%, p < 0.001). Robotic operations comprised 53% of operations post-implementation. On univariate analysis, patients in the post-implementation era had a shorter LOS vs. pre-implementation, regardless of surgical approach (mean 4.7 vs. 6.0 days, p = 0.04). On multivariate analysis, patients who underwent MIS had a shorter LOS [median 4 days (IQR 2–6 days) vs. 7 days (6–9 days), p < 0.001] and were more likely to be discharged home than to inpatient facilities [OR (95% CI) 13.00 (1.61–104.70), p = 0.02]. Robotic thoracic surgery program implementation at a VAMC decreased patient LOS and increased the likelihood of discharging home. Implementation at other VAMCs may be associated with improvement in some patient outcomes.
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13
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Novel treatment strategies for acetylcholine receptor antibody-positive myasthenia gravis and related disorders. Autoimmun Rev 2022; 21:103104. [PMID: 35452851 DOI: 10.1016/j.autrev.2022.103104] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/18/2022] [Indexed: 11/21/2022]
Abstract
The presence of autoantibodies directed against the muscle nicotinic acetylcholine receptor (AChR) is the most common cause of myasthenia gravis (MG). These antibodies damage the postsynaptic membrane of the neuromuscular junction and cause muscle weakness by depleting AChRs and thus impairing synaptic transmission. As one of the best-characterized antibody-mediated autoimmune diseases, AChR-MG has often served as a reference model for other autoimmune disorders. Classical pharmacological treatments, including broad-spectrum immunosuppressive drugs, are effective in many patients. However, complete remission cannot be achieved in all patients, and 10% of patients do not respond to currently used therapies. This may be attributed to production of autoantibodies by long-lived plasma cells which are resistant to conventional immunosuppressive drugs. Hence, novel therapies specifically targeting plasma cells might be a suitable therapeutic approach for selected patients. Additionally, in order to reduce side effects of broad-spectrum immunosuppression, targeted immunotherapies and symptomatic treatments will be required. This review presents established therapies as well as novel therapeutic approaches for MG and related conditions, with a focus on AChR-MG.
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Su KW, Luketich JD, Sarkaria IS. Robotic Assisted Minimally Invasive Thymectomy for Myasthenia Gravis with Thymoma. JTCVS Tech 2022; 13:270-274. [PMID: 35711186 PMCID: PMC9196941 DOI: 10.1016/j.xjtc.2022.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 11/19/2021] [Accepted: 02/17/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
| | | | - Inderpal S. Sarkaria
- Address for reprints: Inderpal S. Sarkaria, MD, Shadyside Medical Building, 5200 Centre Ave, Suite 715, Pittsburgh, PA 15232.
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15
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Aljaafari D, Ishaque N. Thymectomy in myasthenia gravis: A narrative review. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2022; 10:97-104. [PMID: 35602390 PMCID: PMC9121707 DOI: 10.4103/sjmms.sjmms_80_22] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/20/2022] [Accepted: 04/21/2022] [Indexed: 11/04/2022] Open
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16
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Gao J, Jin C, Ao YQ, Tang J, Ding JY, Dong JH, Jiang JH. Minimally invasive thymectomy for myasthenia gravis: a 7-year retrospective study. Gland Surg 2021; 10:3342-3350. [PMID: 35070894 PMCID: PMC8749093 DOI: 10.21037/gs-21-756] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/15/2021] [Indexed: 08/31/2023]
Abstract
BACKGROUND Thymectomy has been identified as an effective strategy for patients with myasthenia gravis (MG) and thymic masses. However, the best surgical approach remains a matter of debate. The aim of the present study was to compare the surgical and neurological outcomes of video-assisted thoracoscopic thymectomy with a modified subxiphoid and bilateral approach in patients with MG and thymic masses. METHODS From August 2013 to April 2018, 68 patients who were diagnosed with MG and thymic masses and underwent video-assisted thoracoscopic thymectomy with a modified subxiphoid (44 patients) or bilateral (24 patients) approach were included in this retrospective study. The surgical and neurological results were analyzed with propensity score matching. RESULTS After propensity score matching, the modified subxiphoid approach in video-assisted thoracoscopic thymectomy resulted in an obviously shorter operative time (P=0.00), drainage duration (P=0.00), less intraoperative blood loss (P=0.00), and shorter postoperative hospital stay (P=0.01). In terms of neurological outcomes, no significant difference was observed in the improvement in MG, with 2-year complete stable remission rates of 21.1% and 26.3% (P=0.68) and 2-year pharmacological remission rates of 31.6% and 26.3% (P=0.60) for the bilateral and subxiphoid approaches, respectively. Additionally, the approaches resulted in similar effects on the magnitudes of decrease in the prednisolone and pyridostigmine doses after 2 years, with average pyridostigmine dose reductions of 72.2% and 71.1% (P=0.78) and average prednisolone reductions of 76.8% and 71.7% (P=0.96) for the bilateral and subxiphoid approaches, respectively. CONCLUSIONS The modified subxiphoid approach was found to be superior to the bilateral approach in video-assisted thoracic surgery thymectomy in terms of the surgical outcomes and yielded similar neurological outcomes. Therefore, the modified subxiphoid approach is recommended as an alternative to the bilateral approach in the treatment of patients with MG and thymic masses.
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Affiliation(s)
- Jian Gao
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun Jin
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Thoracic Surgery, Changhai hospital, Naval Military Medical University, Shanghai, China
| | - Yong-Qiang Ao
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie Tang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian-Yong Ding
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-Hong Dong
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jia-Hao Jiang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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17
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Raza B, Dhamija A, Abbas G, Toker A. Robotic thymectomy for myasthenia gravis surgical techniques and outcomes. J Thorac Dis 2021; 13:6187-6194. [PMID: 34795970 PMCID: PMC8575861 DOI: 10.21037/jtd-2019-rts-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder in which antibodies are produced against post-synaptic acetylcholine receptors, thereby causing impairment of neuromuscular transmission. Diagnosis of MG is confirmed with the AChR antibody test and via an Electromyography. Although medical treatment with acetylcholinesterase inhibitors remains the main treatment of MG, in recent years thymectomy has become an integral part of the treatment algorithm. Numerous factors such as the Patient’s age, presence of AChR antibodies, or MuSK antibody, the severity of disease affect the decision of preforming the thymectomy. Historically thymectomy was preformed via sternotomy associated with significant morbidity. Advancement in the minimally invasive approaches to thymic resection has led to more acceptance of thymectomy in the management of MG. Among these approaches, robotic thymectomy is gaining popularity across the globe due to the unique advantages of the robotic platform like 3D visibility, enhanced dexterity, and wrist like articulating movements of instruments. This has led to less post-operative pain and morbidity; faster recovery and shorter hospital stay. Successful treatment of MG requires a multi-modality approach, which has led to the formation of MG teams in most academic centers, comprising of a specialist neurologist, intensivist, and thoracic surgeon. In this article, we describe the techniques and outcomes of the robotic thymectomy for MG.
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Affiliation(s)
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ghulam Abbas
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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18
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Marcuse F, Hochstenbag M, De Baets MHV, Bootsma G, Maat APWM, Hoeijmakers JGJ, Keijzers M, Abdul Hamid M, De Ruysscher D, Maessen JG. Robotic thymectomy for thymomas: a retrospective follow-up study in the Netherlands. Ann Thorac Surg 2021; 114:1886-1894. [PMID: 34736927 DOI: 10.1016/j.athoracsur.2021.09.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/18/2021] [Accepted: 09/23/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Maastricht University Medical Center+ (MUMC+) is a Dutch center of expertise, appointed by the Netherlands Federation of University Medical Centres (NFU), for the treatment of thymomas. The aim of this study was to investigate the long-term oncological-, surgical-, and neurological outcomes of all patients who underwent a robotic thymectomy for a thymoma at the MUMC+. METHODS We retrospectively analyzed the clinical-pathological data of all consecutive patients with a thymoma who underwent robotic thymectomy using the DaVinci® Robotic System at the MUMC+ between April 2004 and December 2018. Follow-up data were collected from 60 referring Dutch hospitals. RESULTS In total, 398 robotic thymectomies were performed and 130 thymomas (32.7%) were found. Median follow-up time, procedure time and hospitalization were 46 months, 116 minutes and 3 days, respectively. In 8.4% of the patients a conversion was performed and in 20.8% a complication was registered. The majority of myasthenic patients with a thymoma went into remission, mostly within 12 to 24 months after thymectomy (81.0%). No statistical difference was found in the number of complications, conversions, incomplete resections or deaths between patients with myasthenia gravis and nonmyasthenic patients. Thirty-six patients (27.7%) underwent postoperative radiotherapy. The recurrence rate was 9.1% and the five-year thymoma-related survival rate was 96.6% . CONCLUSIONS Robotic thymectomy was found to be safe and feasible in early-stage thymomas, most advanced-stage thymomas and thymomatous myasthenia gravis. A national guideline could contribute to the improvement of the oncological follow-up of thymic epithelial tumors in the Netherlands.
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Affiliation(s)
- Florit Marcuse
- Department of Pulmonology, Maastricht University Medical Center+, Maastricht, Netherlands.
| | - Monique Hochstenbag
- Department of Pulmonology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Marc H V De Baets
- School for Mental Health and Neuroscience, Maastricht University+, Maastricht, Netherlands; Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Gerben Bootsma
- Department of Pulmonology, Zuyderland Medical Center, Heerlen, Netherlands
| | - Alexander P W M Maat
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Janneke G J Hoeijmakers
- School for Mental Health and Neuroscience, Maastricht University+, Maastricht, Netherlands; Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Marlies Keijzers
- Department of Vascular Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Myrurgia Abdul Hamid
- Department of Pathology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, Netherlands
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Minervini F, Boschetti L, Gregor M, Provencio M, Calvo V, Kestenholz PB, Lampridis S, Patrini D, Bertoglio P, Azenha LF, Sergi CM, Kocher GJ. Thymic tumours: a single center surgical experience and literature review on the current diagnosis and management of thymic malignancies. Gland Surg 2021; 10:3128-3140. [PMID: 34926228 PMCID: PMC8637068 DOI: 10.21037/gs-21-517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/07/2021] [Indexed: 08/10/2024]
Abstract
OBJECTIVE This study aimed to provide an extensive overview of clinical and pathological findings along with various therapeutic options analyzing in addiction, retrospectively, the surgical outcomes of a single center cohort. BACKGROUND Thymic neoplasms are rare thoracic tumors which commonly are located in the anterior mediastinum and are associated with a wide spectrum of clinical presentations. They may run an indolent course or could present a very aggressive biologic progression with infiltration of mediastinal structures and presence of distant metastases. The pathogenesis of these tumors is so far not completely clear. Several treatment modalities in a multidisciplinary setting have to be considered in order to provide the best treatment for patients affected by thymic tumors. METHODS We conducted a retrospective cohort analysis of all patients who underwent surgery due to thymic tumor in a university hospital located in Switzerland (Bern University Hospital) and then we performed a narrative review of the English literature using PubMed, Embase, Cochrane Database of Systematic Reviews and Scopus. CONCLUSIONS Minimally invasive techniques play an important role in the treatment of thymic tumors. A careful patients selection in a multidisciplinary setting is mandatory in order to offer the best treatment for patients affected by thymic tumors.
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Affiliation(s)
- Fabrizio Minervini
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Laura Boschetti
- Department of Hematology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Michael Gregor
- Department of Hematology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Mariano Provencio
- Department of Medical Oncology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Virginia Calvo
- Department of Medical Oncology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Peter B. Kestenholz
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Savvas Lampridis
- Department of Thoracic Surgery, 424 General Military Hospital, Thessaloniki, Greece
| | - Davide Patrini
- Department of Thoracic Surgery, University College London Hospitals, London, UK
| | - Pietro Bertoglio
- Division of Thoracic Surgery, IRCSS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - L. Filipe Azenha
- Department of Thoracic Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Consolato M. Sergi
- Division of Anatomic Pathology, Children’s Hospital of Eastern Ontario, University of Ottawa, Ontario, Canada
| | - Gregor J. Kocher
- Division of Thoracic Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
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Navarrete-Arellano M. Robotic-Assisted Minimally Invasive Surgery in Children. LATEST DEVELOPMENTS IN MEDICAL ROBOTICS SYSTEMS 2021. [DOI: 10.5772/intechopen.96684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.
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21
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Park S. Robot-Assisted Thoracic Surgery Thymectomy. J Chest Surg 2021; 54:319-324. [PMID: 34353974 PMCID: PMC8350461 DOI: 10.5090/jcs.21.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022] Open
Abstract
Robotic thymectomy has been adopted recently and has been shown to be safe and feasible in treating thymic tumors and myasthenia gravis. The surgical indications of robotic technology are expanding, with advantages including an excellent surgical view and sophisticated manipulation. Herein, we describe technical aspects, considerations, and outcomes of robotic thymectomy.
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Affiliation(s)
- Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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22
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Wu WJ, Zhang FY, Xiao Q, Li XK. Does robotic-assisted thymectomy have advantages over video-assisted thymectomy in short-term outcomes? A systematic view and meta-analysis. Interact Cardiovasc Thorac Surg 2021; 33:385-394. [PMID: 33997899 DOI: 10.1093/icvts/ivab109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/27/2021] [Accepted: 03/09/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES A thymic epithelial tumour is the most common primary tumour in the anterior mediastinum of adults. A few retrospective studies compared the short-term outcomes between robotic-assisted thymectomy (RAT) and video-assisted thymectomy (VAT). So, it is necessary to conduct a meta-analysis to further compare these 2 surgical techniques. METHODS EMBASE, Medline and Web of Science were used. Thesaurus terms and medical subject headings were used in Medline and EMBASE, respectively. The Newcastle-Ottawa scale was used for grading because the included studies were all case-control studies. RESULTS Nine studies were included in the meta-analysis with a total of 723 patients, including 315 patients in the RAT group and 408 patients in the VAT group. The meta-analysis [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.06-0.94; P = 0.041], indicating that RAT yielded a significantly lower rate of conversion compared with VAT. Duration of drainage with RAT was significantly less than that with VAT (weighted mean difference = -1.10; 95% CI -1.98 to -0.22; P = 0.014). The pooled analysis (weighted mean difference = -103.6; 95% CI -199.21 to -7.98; P = 0.034) suggested that patients in the RAT group had less drainage than those in the VAT group. The recurrence rates in both groups were comparable (OR 0.19, 95% CI 0.03-1.20; P = 0.078). CONCLUSIONS RAT has advantages over VAT in terms of short-term outcomes such as shorter duration of drainage, less total drainage and a lower rate of conversion. The recurrence rate was comparable between the 2 techniques. Therefore, RAT could be considered as an alternative treatment for diseases of the thymus.
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Affiliation(s)
- Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Fu-Yu Zhang
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Qin Xiao
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Xiao-Kun Li
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Medicine School of Southeast University, Nanjing, China
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Solis-Pazmino P, Baiu I, Lincango-Naranjo E, Trope W, Prokop L, Ponce OJ, Shrager JB. Impact of the Surgical Approach to Thymectomy Upon Complete Stable Remission Rates in Myasthenia Gravis: A Meta-analysis. Neurology 2021; 97:e357-e368. [PMID: 33947783 DOI: 10.1212/wnl.0000000000012153] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/11/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To determine whether the available operative techniques for thymectomy in myasthenia gravis (MG) confer variable chances for achieving complete stable remission (CSR), we performed a meta-analysis of comparative studies of surgical approaches to thymectomy. METHODS Meta-analysis was done of all studies providing comparative data on thymectomy approaches, with CSR reported and minimum 3-year mean follow-up. RESULTS Twelve cohort studies and 1 randomized clinical trial, containing 1,598 patients, met entry criteria. At 3 years, CSR from MG was similar after video-assisted thoracoscopic (VATS) extended vs both basic (relative risk [RR] 1.00, p = 1.00, 95% confidence interval [CI] 0.39-2.58) and extended (RR 0.96, p = 0.74, 95% CI 0.72-1.27) transsternal approaches. CSR at 3 years was also similar after extended transsternal vs combined transcervical-subxiphoid (RR 1.08, p = 0.62, 95% CI 0.8-1.44) approaches. VATS extended approaches remained statistically equivalent to extended transsternal approaches through 9 years of follow-up (RR 1.51, p = 0.05, 95% CI 0.99-2.30). The only significant difference in CSR rate between a traditional open and a minimally invasive approach was seen at 10 years when the now-abandoned basic (non-sternum-lifting) transcervical approach was compared to the extended transsternal approach (RR 0.4, p = 0.01, 95% CI 0.2-0.8). CONCLUSIONS A significant difference in the rate of CSR among various surgical approaches for thymectomy in MG was identified only at long-term follow-up and only between what might be considered the most aggressive approach (extended transsternal thymectomy) and the least aggressive approach (basic transcervical thymectomy). Extended minimally invasive approaches appear to have CSR rates equivalent to those of extended transsternal approaches and are therefore appropriate in the hands of experienced surgeons.
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Affiliation(s)
- Paola Solis-Pazmino
- From the Division of Thoracic Surgery (P.S.-P., J.B., W.T., J.B.S.), Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA; Knowledge and Evaluation Research Unit (P.S.-P., E.L.-N., L.P., O.J.P.), Mayo Clinic, Rochester, MN; Universidad Central (E.L.-N.), Medical School, Quito, Ecuador; Unidad de Conocimiento y Evidencia (O.J.P.), Universidad Peruana Cayetano Heredia, Lima, Perú; and Department of Surgery (J.B.S.), Veterans Affair Palo Alto Health Care System, CA
| | - Ioana Baiu
- From the Division of Thoracic Surgery (P.S.-P., J.B., W.T., J.B.S.), Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA; Knowledge and Evaluation Research Unit (P.S.-P., E.L.-N., L.P., O.J.P.), Mayo Clinic, Rochester, MN; Universidad Central (E.L.-N.), Medical School, Quito, Ecuador; Unidad de Conocimiento y Evidencia (O.J.P.), Universidad Peruana Cayetano Heredia, Lima, Perú; and Department of Surgery (J.B.S.), Veterans Affair Palo Alto Health Care System, CA
| | - Eddy Lincango-Naranjo
- From the Division of Thoracic Surgery (P.S.-P., J.B., W.T., J.B.S.), Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA; Knowledge and Evaluation Research Unit (P.S.-P., E.L.-N., L.P., O.J.P.), Mayo Clinic, Rochester, MN; Universidad Central (E.L.-N.), Medical School, Quito, Ecuador; Unidad de Conocimiento y Evidencia (O.J.P.), Universidad Peruana Cayetano Heredia, Lima, Perú; and Department of Surgery (J.B.S.), Veterans Affair Palo Alto Health Care System, CA
| | - Winston Trope
- From the Division of Thoracic Surgery (P.S.-P., J.B., W.T., J.B.S.), Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA; Knowledge and Evaluation Research Unit (P.S.-P., E.L.-N., L.P., O.J.P.), Mayo Clinic, Rochester, MN; Universidad Central (E.L.-N.), Medical School, Quito, Ecuador; Unidad de Conocimiento y Evidencia (O.J.P.), Universidad Peruana Cayetano Heredia, Lima, Perú; and Department of Surgery (J.B.S.), Veterans Affair Palo Alto Health Care System, CA
| | - Larry Prokop
- From the Division of Thoracic Surgery (P.S.-P., J.B., W.T., J.B.S.), Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA; Knowledge and Evaluation Research Unit (P.S.-P., E.L.-N., L.P., O.J.P.), Mayo Clinic, Rochester, MN; Universidad Central (E.L.-N.), Medical School, Quito, Ecuador; Unidad de Conocimiento y Evidencia (O.J.P.), Universidad Peruana Cayetano Heredia, Lima, Perú; and Department of Surgery (J.B.S.), Veterans Affair Palo Alto Health Care System, CA
| | - Oscar J Ponce
- From the Division of Thoracic Surgery (P.S.-P., J.B., W.T., J.B.S.), Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA; Knowledge and Evaluation Research Unit (P.S.-P., E.L.-N., L.P., O.J.P.), Mayo Clinic, Rochester, MN; Universidad Central (E.L.-N.), Medical School, Quito, Ecuador; Unidad de Conocimiento y Evidencia (O.J.P.), Universidad Peruana Cayetano Heredia, Lima, Perú; and Department of Surgery (J.B.S.), Veterans Affair Palo Alto Health Care System, CA
| | - Joseph B Shrager
- From the Division of Thoracic Surgery (P.S.-P., J.B., W.T., J.B.S.), Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA; Knowledge and Evaluation Research Unit (P.S.-P., E.L.-N., L.P., O.J.P.), Mayo Clinic, Rochester, MN; Universidad Central (E.L.-N.), Medical School, Quito, Ecuador; Unidad de Conocimiento y Evidencia (O.J.P.), Universidad Peruana Cayetano Heredia, Lima, Perú; and Department of Surgery (J.B.S.), Veterans Affair Palo Alto Health Care System, CA.
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Seo YJ, Christian-Miller N, Aguayo E, Sanaiha Y, Benharash P, Yanagawa J. National Use and Short-term Outcomes of Video and Robot-Assisted Thoracoscopic Thymectomies. Ann Thorac Surg 2021; 113:230-236. [PMID: 33607051 DOI: 10.1016/j.athoracsur.2021.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transsternal open thymectomy has long been the most widely used approach for thymectomy, but recent decades have seen the introduction of minimally invasive surgery (MIS), such as video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) thymectomy. This retrospective cohort study provides a national comparison of trends, outcomes, and resource utilization of open, VATS, and RATS thymectomy. METHODS Admissions for thymectomies from 2008 to 2014 were identified in the National Inpatient Sample. Patients were identified as undergoing open, VATS, or RATS thymectomy. Propensity score-matched analyses were used to compare overall complication rates, length of stay (LOS), and cost of VATS and RATS thymectomies. RESULTS An estimated 23,087 patients underwent thymectomy during the study period: open in 16,025 (69%) and MIS in 7217 (31%). Of the MIS cohort, 4119 (18%) underwent VATS and 3097 (13%) underwent RATS. Performance of RATS and VATS thymectomy increased while that of open thymectomy declined. Baseline characteristics between VATS and RATS were similar, except more women underwent VATS thymectomy. No differences in LOS or overall complication rates were appreciable in this study. VATS was associated with the lowest cost of the 3 approaches. CONCLUSIONS Our findings demonstrate the increasing adoption of MIS and declining use of the open surgical approach for thymectomy. There are no differences in overall complication rates between RATS and VATS thymectomy, but RATS is associated with greater cost and lower cardiac complication rates.
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Affiliation(s)
- Young-Ji Seo
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | | | - Esteban Aguayo
- David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California
| | - Jane Yanagawa
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California.
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Abstract
The proportion of robot-assisted thoracic surgery (RATS) is continuously increasing. The main areas of clinical application are anatomical lung resections with lymphadenectomy and resection of mediastinal tumors. Especially in the area of the thymus robot-assisted procedures can now be considered the gold standard. Overall, the limitations of video-assisted thoracoscopic surgery (VATS) can be overcome by the use of robot-assisted surgery and thus a larger proportion of patients can be treated with minimally invasive procedures. The safety of the RATS procedure has been repeatedly demonstrated, although it remains difficult to demonstrate scientifically measurable benefits. With the introduction of new systems on the market further technical evolution and improvement can be expected in the future.
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Role of thymus on prognosis of myasthenia gravis in Turkish population. North Clin Istanb 2020; 7:452-459. [PMID: 33163880 PMCID: PMC7603859 DOI: 10.14744/nci.2020.51333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 04/29/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE: Myasthenia gravis (MG) is an autoimmune disease that may cause a disorder in transmission at the neuromuscular junction. Antibodies directed against acetylcholine receptors are responsible. The thymus is the place that that production of these antibodies mainly occurs. The thymus gland abnormalities and abnormal production of these antibodies are associated with MG. Consequently, thymectomy is a common treatment for MG. The nature of the disease makes it difficult to plan prospective, controlled trials; therefore, there is no current consensus among clinicians on a single algorithm of treatment, and the approach is frequently based on the observations and experiences of experts. The contributions to the literature largely consist of retrospective studies examining an approach to treatment and the effects of thymectomy on prognosis. In this retrospective study, evaluation of Turkish patients with myasthenia gravis was carried out for the importance of thymectomy and effects on prognosis. METHODS: In this study, 93 patients with myasthenia gravis whose followed up at Neuromuscular outpatient clinic between 1998–2018 were evaluated retrospectively. Type of disease, antibody status, treatment, thymectomy, thymus pathology and prognosis were assessed. RESULTS: Thymectomy had been a positive effect on the prognosis of the disease independent of the duration of disease and thymic pathology. The best results had been obtained with early thymectomy with short disease duration, younger age and patients with thymic hyperplasia. Success of therapy was limited with thymoma. With advanced age need for thymectomy was decreased. CONCLUSION: In the present study, evaluation of 93 patients with myasthenia gravis was done retrospectively and it was concluded that thymectomy had a positive effect on prognosis, especially in young patients when performed as early as possible. The most successful results were obtained in cases with thymic hyperplasia.
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Eichhorn M, Haag J, Grünewald C, Reimer P, Winter H. [Robot-assisted Mediastinal Mass Resection]. Zentralbl Chir 2020; 146:111-118. [PMID: 32767302 DOI: 10.1055/a-1192-7205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In recent years, robot-assisted thoracic surgery is gaining more and widespread interest in Europe. Due to the narrow space and the complexity of anatomical structures, conventional minimally invasive mediastinal surgery may be challenging for the thoracic surgeon. Robot-assisted mediastinal surgery opens up new possibilities for minimally invasive surgery, as it permits greater dexterity, a three-dimensional view, and tremor adjustment, which allows the surgeon to perform complex procedures in small thoracic spaces. As robotic platforms continue to evolve, more complex mediastinal thoracic surgical interventions will be facilitated, translating to improved outcomes for patients. This article provides an overview of the current status of robot-assisted mediastinal surgery and summarises general aspects of the indication, set-up and steps of robot-assisted thoracoscopic surgery in mediastinal mass resections.
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Affiliation(s)
- Martin Eichhorn
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Deutschland, Translational Lung Research Center (TLRCH) Heidelberg, Deutsches Zentrum für Lungenforschung (DZL)
| | - Johannes Haag
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Deutschland, Translational Lung Research Center (TLRCH) Heidelberg, Deutsches Zentrum für Lungenforschung (DZL)
| | - Christiane Grünewald
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Deutschland, Translational Lung Research Center (TLRCH) Heidelberg, Deutsches Zentrum für Lungenforschung (DZL)
| | - Peter Reimer
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Deutschland, Translational Lung Research Center (TLRCH) Heidelberg, Deutsches Zentrum für Lungenforschung (DZL)
| | - Hauke Winter
- Chirurgische Abteilung, Thoraxklinik, Universitätsklinikum Heidelberg, Deutschland, Translational Lung Research Center (TLRCH) Heidelberg, Deutsches Zentrum für Lungenforschung (DZL)
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Li XK, Xu Y, Cong ZZ, Zhou H, Wu WJ, Shen Y. Comparison of the progression-free survival between robot-assisted thymectomy and video-assisted thymectomy for thymic epithelial tumors: a propensity score matching study. J Thorac Dis 2020; 12:4033-4043. [PMID: 32944315 PMCID: PMC7475562 DOI: 10.21037/jtd-20-1065] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Robotic system was recently introduced to assist surgeons in performing thymectomy. However, whether robot-assisted thoracoscopic thymectomy (RATT) could replace video-assisted thoracoscopic thymectomy (VATT) and be considered as a superior treatment for thymic epithelial tumors is still controversial. The aim of this study was to evaluate the progression-free survival (PFS) and short-term clinical outcomes in patients undergoing RATT or VATT by comparing the matched two groups after performing propensity score analysis. Methods We retrospectively reviewed the clinical data of 295 patients diagnosed with thymic epithelial tumors. There were 60 patients in RATT group and 235 in VATT group. Propensity score matching was done between two groups with variables of age, gender, tumor size, organization histologic classification, original Masaoka stages, presence of myasthenia gravis (MG) and adjuvant therapy. Sixty patients from the RATT group and 60 from the VATT group were matched, fitting the model. The PFS and short-term clinical outcomes of matched groups were compared. Results After matching, the surgical time in RATT groups was significant shorter than that in VATT groups (P=0.042). Loco-regional recurrence and distal metastasis were detected in 4 patients with thymoma and 1 patient with thymic carcinoma in RATT group and in 25 patients with thymoma and 3 patients with thymic carcinoma in VATT group before matching. PFS were estimated in only thymoma cases. The PFS in RATT group (n=55) intended to be longer than that in VATT group (n=58) after matching (5-year PFS rate: 81.5% and 75.4%, respectively; log-rank P=0.095). Conclusions RATT has the superiorities over VATT on short-term outcomes due to enabling surgeons to operate in a stable and comfortable environment. Meanwhile, RATT yielded a longer PFS compared with VATT, although the difference was not significant. Therefore, RATT could be considered as a standard approach for the treatment of thymic epithelial tumors.
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Affiliation(s)
- Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Hai Zhou
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
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Abstract
Resection is the mainstay of treatment for thymic epithelial tumors (TETs), with complete removal of the tumor and involved organs being the ultimate aim. The choice of surgical approach plays a major role in defining treatment success, and the optimal choice of method should thus provide an adequate surgical view to achieve complete tumor resection. While median sternotomy is considered the gold standard for access to the mediastinum, several minimally invasive approaches to thymectomy have been described, including video-assisted robotic-assisted thymectomy, although the oncological outcomes of that procedure remain unclear. A multimodal approach incorporating chemotherapy or chemoradiotherapy followed by extended surgery may improve resectability and outcomes for patients with advanced TETs. Surgical debulking is also reportedly acceptable for invasive thymoma because of its potential for achieving favorable outcomes. Re-resection is an acceptable option for patients with recurrent thymoma after initial resection, and repeat resection for recurrent pleural dissemination seems effective. Here, the literature on current clinical practices in the surgical management and treatment of TETs is reviewed.
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Imielski B, Kurihara C, Manerikar A, Chaudhary S, Kosterski S, Odell D, Kim S, Bharat A. Comparative effectiveness and cost-efficiency of surgical approaches for thymectomy. Surgery 2020; 168:737-742. [PMID: 32641277 DOI: 10.1016/j.surg.2020.04.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/09/2020] [Accepted: 04/16/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND We compared the clinical outcomes and cost-efficiency of surgical approaches (sternotomy-open, video assisted thoracoscopic surgery, and robotic assisted thoracic surgery) for thymectomy. METHODS This is a retrospective review of 220 consecutive patients who underwent thymectomy between January 1, 2007, and January 31, 2017. Surgical approach was determined by the surgeon, but we only included cases that could be resected using any of the 3 approaches. RESULTS Open approach was used in 69 patients, whereas minimally invasive technique was used in 151 (97, video assisted thoracoscopic surgery; 54, robotic assisted thoracic surgery). Open surgery was associated with greater total hospital cost ($22,847 ± $20,061 vs $14,504 ± $10,845, P < .001). Open group also revealed longer duration of intensive care unit (1.2 ± 2.8 vs 0.2 ± 1.3 days, P < .001) and hospital stay (4.3 ± 4.0 vs 2.0 ± 2.6 days, P < .001). There were no differences in major adverse clinical outcomes. Long-term recurrence-free survival after resection of thymoma was similar between the groups. CONCLUSION Minimally invasive techniques were equally efficacious compared with the open approach in the resection of the thymus. Additionally, their use was associated with decreased hospital duration of stay and reduced cost. Hence the use of minimally invasive approaches should be encouraged in the resection of thymus.
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Affiliation(s)
- Bartlomiej Imielski
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Chitaru Kurihara
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Adwaiy Manerikar
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Satya Chaudhary
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Susan Kosterski
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David Odell
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Samuel Kim
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ankit Bharat
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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Abbas AES. A New Testament for the Followers of Thymic Epithelial Tumors. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:211-224. [PMID: 32438846 DOI: 10.1177/1556984520922932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Abbas El-Sayed Abbas
- 12314 Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelpia, PA, USA.,Division of Thoracic Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Kauppi J, Atula S, Strbian D, Robinson E, Alho H, Sihvo E, Ilonen I, Räsänen J. Improvement in symptom remission rate following robotic thymectomy in patients with myasthenia gravis. Interact Cardiovasc Thorac Surg 2020; 30:827-833. [DOI: 10.1093/icvts/ivaa021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 02/06/2023] Open
Abstract
Abstract
OBJECTIVES
We investigated long-term symptom control of myasthenia gravis following robotic-assisted thoracic surgery (RATS) versus video-assisted thoracic surgery (VATS) thymectomy in a retrospective single-centre cohort.
METHODS
From 1999 to 2015, a total of 147 patients underwent thymectomy for myasthenia gravis. Demographic data, medications, operative details, hospital length of stay (LOS), procedure complications and follow-up data were collected by chart review. The Myasthenia Gravis Foundation of America classification was used to evaluate preoperative and postoperative myasthenia gravis status. The primary outcome was complete stable remission (CSR) status.
RESULTS
Of the 147 patients, 86 (59%) patients underwent VATS thymectomy and 61 (42%) patients underwent RATS thymectomy. There was no operative mortality. The median follow-up was 12 years in the VATS group [interquartile range (IQR) 9–14 years] and 5 years in the RATS group (IQR 3–6 years) (P = 0.001). Two patients in the VATS (2%) and 2 patients (3%) in the RATS group had Clavien–Dindo grade 3 complications. The median LOS was 3 days in the VATS group (IQR 2–4 days) and 2 days in the RATS group (IQR 2–3 days) (P = 0.013). The rate of CSR was 18% (14/65) in the VATS group compared to 26% (16/44) in the RATS group (P = 0.06). Younger age, RATS approach and preoperative medical remission were independently predictive of CSR by Cox regression analysis.
CONCLUSIONS
Patients who underwent RATS thymectomy and were younger or medically remitted before surgery were more likely to achieve CSR. Both methods yield excellent perioperative outcome.
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Affiliation(s)
- Juha Kauppi
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Sari Atula
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Eric Robinson
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hanni Alho
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Eero Sihvo
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Ilkka Ilonen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Jari Räsänen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
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Navarrete-Arellano M. Thoracic surgery by minimally invasion robot-assisted in children: “experience and current status”. MINI-INVASIVE SURGERY 2020. [DOI: 10.20517/2574-1225.2019.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Aim: We report our experience in minimally invasive thoracic robot-assisted surgery in children, and a current analysis is carried out on this topic.
Methods: Observational, prospective, and longitudinal studies were performed for children with thoracic pathology treated with robotic surgery, from March 2015 to April 2019. We used the “da Vinci surgical system” (Intuitive Surgical, Inc., Sunnyvale, CA. USA). Registered variables included demographic data, diagnosis, surgery, total time, time of console surgery, bleeding, hemotransfusions, conversions, complications, postoperative (PO) stay, and follow-up. Measures of central tendency were used. Research Ethics Committee of Hospital approved the study. We conducted a detailed non-systematic review of previous publications of children undergoing thoracic robotic surgery.
Results: We treated 11 children, with average age of 5.7 years and weight of 21.3 kg. Diagnosis were: congenital cystic adenomatoid malformation, intralobar sequestration, diaphragmatic paralysis, diaphragmatic eventration, mediastinal teratoma, Ewing’s tumor of the fourth left rib, and pulmonary tuberculosis. Surgeries performed were: four lobectomies, four diaphragmatic plications, two tumor resections, and a case of pleural and lung biopsies. The average of console surgery time was 166.45 min, PO stay was 3.6 days, and follow-up was 24.7 months. Conversions and PO complications were 9.1%, and there were no intraoperative complications and mortality. Currently, the number of children treated with thoracic robot-assisted surgery has barely reached 100 cases.
Conclusion: Our results are encouraging, although our experience is limited to a few cases. Robotic surgery for the treatment of thoracic pathology is feasible and safe, and has advantages. To date, very few patients have been treated, and few pediatric surgeons worldwide have applied thoracic robotic surgery in children.
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Şehitogullari A, Nasır A, Anbar R, Erdem K, Bilgin C. Comparison of perioperative outcomes of videothoracoscopy and robotic surgical techniques in thymoma. Asian J Surg 2020; 43:244-250. [DOI: 10.1016/j.asjsur.2019.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 04/06/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022] Open
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Tianci C, Shen Z, Chen S, Lin Y, Gao L, Zhang Z, Kang M, Lin J. Median sternotomy versus minimally invasive thymectomy for early-stage thymoma: A systematic review and meta-analysis protocol. Medicine (Baltimore) 2019; 98:e18359. [PMID: 31860993 PMCID: PMC6940122 DOI: 10.1097/md.0000000000018359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The completeness of resection is an important prognostic factor for early resectable thymoma. Since its inception 2 decades ago, median sternotomy has been recognized as the gold standard method for the treatment of all types and stages of thyomas. Minimally invasive surgical techniques, including video-assisted and robot-assisted surgery, have been rapidly developed as an alternative to traditional open approach surgery. Compared with traditional open approach surgery, minimally invasive approach has better cosmetic effect, faster improvement of lung function, reduction of surgical trauma, length of stay, and complications. We believe that this is an appropriate time and there is a need for a systematic, comprehensive, and objective assessment of the 2 surgical modalities in order to provide reliable evidence for clinicians to determine the best treatment for patients with early resectable thymoma. METHODS Pubmed (Medline), Web of Science, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar will be searched for relevant randomized controlled trials (RCTs), quasi-RCTs, and Hi-Q (high quality) prospective cohort trials published or unpublished in any language before March 1, 2020. Subgroup analysis will be performed in tumor pathological stage and ethnicity. PROSPERO registration number: CRD42019133724. RESULTS The results of this study will be published in a peer-reviewed journal. CONCLUSION This study will be the first to assess the efficacy and safety of median sternotomy recognized as the gold standard method for the treatment of all types and stages of thyomas and minimally invasive thymectomy for patients with early-stage thymoma. This study will assess whether minimally invasive thoracoscopic and robotic assisted thymectomy can be used as an alternative to traditional median sternotomy for patients with early resectable thymoma and provide high-quality and reliable evidence for clinicians' decision-making.
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Affiliation(s)
- Chai Tianci
- Department of Thoracic Surgery, Fujian Medical University Union Hospital
| | - Zhimin Shen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital
| | - Sui Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital
| | - Yuhan Lin
- School of Stomatology, Fujian Medical University, Fuzhou, China
| | - Lei Gao
- Department of Thoracic Surgery, Fujian Medical University Union Hospital
| | - Zhenyang Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital
| | - Mingqiang Kang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital
| | - Jiangbo Lin
- Department of Thoracic Surgery, Fujian Medical University Union Hospital
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Li F, Li Z, Takahashi R, Ioannis A, Ismail M, Meisel A, Rueckert JC. Robotic-Extended Rethymectomy for Refractory Myasthenia Gravis: A Case Series. Semin Thorac Cardiovasc Surg 2019; 32:593-602. [PMID: 31682904 DOI: 10.1053/j.semtcvs.2019.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 11/11/2022]
Abstract
To assess the safety and efficacy of robotic-extended rethymectomy in selected refractory myasthenia gravis (MG) patients with suspected residual thymic tissue. Robotic-extended rethymectomy was performed in 6 MG patients with seropositive acetylcholine receptors (AChR) antibody who had undergone a previous thymectomy (1 cervicotomy, 2 video-assisted thoracoscopic surgeries, and 3 sternotomies). The median observation time before robotic rethymectomy was 108 (24-171) months. The main outcomes were perioperative morbidity, mortality, conversion to open surgery, and clinical outcomes according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). Before rethymectomy, all patients required immunosuppressants and 5 patients (83.3%) required intravenous immune globulin and/or plasma exchange to control the symptoms. The median specimen weight was 24.5 (14-144) g after rethymectomy, and residual thymic tissue was found in 5 patients (83.3%). No conversion to open surgery or perioperative morbidity and mortality was observed. With a median follow-up time of 46.5 (13-155) months, 3 patients (50%) achieved "improved" and 3 (50%) were "unchanged" according to the MGFA-PIS. Compared with preoperative use, the median daily dose of corticosteroids statistically decreased (25 [7.5-60] vs 0 [0-5] mg, P = 0.002) without significant change in azathioprine use (100 [0-200] vs 50 [0-150] mg, P = 0.360). AChR antibody positive MG patients with a treatment refractory long-term course after thymectomy might have remaining thymic tissue with the 2 commonly associated thymus pathologies, thymoma, and follicular hyperplasia. Robotic-extended rethymectomy might be considered as a safe and beneficial treatment option in these patients.
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Affiliation(s)
- Feng Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Zhongmin Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Reona Takahashi
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | | | - Mahmoud Ismail
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology Berlin, Charité University Hospital Berlin, Berlin, Germany
| | - Jens-C Rueckert
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany.
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Li F, Ismail M, Elsner A, Uluk D, Bauer G, Meisel A, Rueckert JC. Surgical Techniques for Myasthenia Gravis. Thorac Surg Clin 2019; 29:177-186. [DOI: 10.1016/j.thorsurg.2018.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Comacchio GM, Marulli G, Mammana M, Natale G, Schiavon M, Rea F. Surgical Decision Making. Thorac Surg Clin 2019; 29:203-213. [DOI: 10.1016/j.thorsurg.2018.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Kido and colleagues in 1999 used for the first time the subxiphoid approach. Recently, video-assisted thoracoscopic surgery (VATS) thymectomy has been improved for the advancement of surgical materials and new instruments. The most important aspect regarding the subxiphoid approach is the possibility to avoid the intercostal nerve damage with the consequence of a decreased use of postoperative analgesics, quite short surgical duration, fast discharge from hospital and a guarantee of successful cosmetics results.
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Li F, Takahashi R, Bauer G, Yousef MS, Hotter B, Swierzy M, McAleenan A, Ismail M, Meisel A, Rueckert JC. Results of Robotic Thymectomy Performed in Myasthenia Gravis Patients Older Than 60 Years at Onset. Ann Thorac Surg 2019; 108:912-919. [PMID: 30885848 DOI: 10.1016/j.athoracsur.2019.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/29/2019] [Accepted: 02/06/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Data are limited on the safety and efficacy of robotic thymectomy in patients with myasthenia gravis (MG) older than 60 years at onset. METHODS Patients older than 60 years at MG onset who underwent robotic thymectomy in Charite Universitaetsmedizin Berlin between 2003 and 2017 were potentially eligible for inclusion. The main outcomes were perioperative complications and clinical outcome according to the Myasthenia Gravis Foundation of America Post-Intervention Status. RESULTS Sixty-eight (25 women, 43 men) of 580 patients with MG who underwent robotic thymectomy were eligible for perioperative analyses (median age at MG onset 67 years, range: 61 to 85 years). The perioperative morbidity rate was 13.2%, and the only perioperative death was due to aortic dissection. Fifty-one patients were available for further analysis with a median follow-up time of 60 months (range: 12 to 263 months). The complete stable remission rate was 7.8%, the improvement rate was 68.6%, and the overall mortality rate was 11.8%. Compared with preoperative use, the mean daily dose of corticosteroid agents was significantly reduced at the last follow-up (17.6 ± 23.6 mg versus 2.6 ± 6.1 mg, p = 0.0001) without increased use of azathioprine (35.9 ± 61.9 mg versus 42.7 ± 59 mg, p = 0.427). After excluding 2 patients seronegative for the anti-acetylcholine receptor antibody, 10 of 49 seropositive patients achieved "good outcome" (including four complete stable remissions, three pharmacologic remissions, and three minimal manifestations 0) which was predicted by being free of concomitant disease (odds ratio 7.307, 95% confidence interval: 1.188 to 44.937, p = 0.032) and Myasthenia Gravis Foundation of America classification I before thymectomy (odds ratio 6.696, 95% confidence interval: 1.259 to 35.620, p = 0.026). CONCLUSIONS Robotic thymectomy seems to be safe and effective in patients with MG older than 60 years at onset with a statistically significant steroid-sparing effect.
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Affiliation(s)
- Feng Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Reona Takahashi
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Gero Bauer
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Mike-S Yousef
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Benjamin Hotter
- Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Marc Swierzy
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Mahmoud Ismail
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Jens-C Rueckert
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany.
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O'Sullivan KE, Kreaden US, Hebert AE, Eaton D, Redmond KC. A systematic review of robotic versus open and video assisted thoracoscopic surgery (VATS) approaches for thymectomy. Ann Cardiothorac Surg 2019; 8:174-193. [PMID: 31032201 DOI: 10.21037/acs.2019.02.04] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Median sternotomy has been the most commonly used approach for thymectomy to date. Recent advances in video-assisted thoracoscopic surgery (VATS) and robotic access with CO2 insufflation techniques have allowed more minimally invasive approaches. However, prior reviews have not compared robotic to both open and VATS thymectomy. Methods A systematic review was conducted in accordance with the PRISMA guidelines using PubMed, Embase and Scopus databases. Original research articles comparing robotic to VATS or to open thymectomy for myasthenia gravis, anterior mediastinal masses, or thymomas were included. Meta-analyses were performed for mortality, operative time, blood loss, transfusions, length of stay, conversion to open, intraoperative and postoperative complication rates, and positive/negative margin rates. Results Robotic thymectomy is a valid alternative to the open approach; advantages include: reduced blood loss [weighted mean difference (WMD): -173.03, 95% confidence interval (95% CI): -305.90, -40.17, P=0.01], fewer postoperative complications (odds ratio: 0.37, 95% CI: 0.22, 0.60, P<0.00001), a shorter hospital stay (WMD: -2.78, 95% CI: -3.22, -2.33, P<0.00001), and a lower positive margin rate (relative difference: -0.04, 95% CI: -0.07, -0.01, P=0.01), with comparable operative times (WMD: 6.73, 95% CI: -21.20, 34.66, P=0.64). Robotic thymectomy was comparable with the VATS approach; both have the advantage of avoiding median sternotomy. Conclusions While randomized controlled studies are required to make definitive conclusions, current data suggests that robotic thymectomy is superior to open surgery and comparable to a VATS approach. Long-term follow-up is required to further delineate oncological outcomes.
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Affiliation(s)
- Katie E O'Sullivan
- Department of Thoracic Surgery, Mater Misericordiae University Hospital, Eccles St., Dublin, Ireland
| | - Usha S Kreaden
- Clinical Affairs, Intuitive Surgical Inc., Sunnyvale, CA, USA
| | - April E Hebert
- Clinical Affairs, Intuitive Surgical Inc., Sunnyvale, CA, USA
| | - Donna Eaton
- Department of Thoracic Surgery, Mater Misericordiae University Hospital, Eccles St., Dublin, Ireland
| | - Karen C Redmond
- Department of Thoracic Surgery, Mater Misericordiae University Hospital, Eccles St., Dublin, Ireland
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Voulaz E, Veronesi G, Infante M, Cariboni U, Testori A, Novellis P, Bottoni E, Passera E, Morenghi E, Alloisio M. Radical thymectomy versus conservative thymomectomy in the surgical treatment of thymic malignancies. J Thorac Dis 2018; 10:4127-4136. [PMID: 30174857 DOI: 10.21037/jtd.2018.06.04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Complete thymectomy is recommended for thymic malignancies to reduce local recurrence and the likelihood of the long-term development of myasthenia gravis (MG). Thymus-conserving surgery (thymomectomy) seems to yield similar results, but evidence is still limited. The objective of this study was to assess if the oncological outcome, in terms of overall survival (OS) and disease-free survival (DFS), are comparable between radical thymectomy vs. conservative thymomectomy patients, and to assess if the outcome of the video-assisted thoracoscopic surgery (VATS) approach was similar to open surgery approach. Methods We retrospectively analyzed 157 consecutive patients with either resectable thymoma or thymic carcinoma from two Italian centers (Humanitas Research Hospital, Milan, and Humanitas Gavazzeni, Bergamo) between 1997 and 2013 who underwent thymomectomy or extended thymectomy with the VATS or open approach; the patients with Miastenia Gravis underwent radical thymectomy. The patients were followed through physical examinations and phone interviews. Results Thymomectomy and thymectomy were performed on 86 (54.8%) and 71 (45.2%) patients, respectively. Prognostic factors and comorbidities were comparable in the two groups. The median follow-up was 77 months. Cox proportional hazards model revealed that Masaoka advanced stage and thymic carcinoma of WHO classification were independent predictive factors for overall survival, but that the extent of surgery and the approach used (minimally invasive versus open) were not. Notably, five- and ten-year survival rates were similar in the two groups. Conclusions In our experience, radical thymectomy and conservative thymomectomy did not differ in terms of disease-free and overall survival rates. In nonmyasthenic patients with early-stage resectable thymic malignancy, minimally invasive thymomectomy provided equivalent results to open thymectomy. Our results should be interpreted with caution due to the retrospective nature of the study. Well-designed, adequately-powered studies should be very welcome to increase the quantity and the quality of clinical evidence before incorporating this procedure in future guidelines.
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Affiliation(s)
- Emanuele Voulaz
- Thoracic Surgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giulia Veronesi
- Thoracic Surgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Maurizio Infante
- Thoracic Surgery Department, University Hospital Borgo Trento, Verona, Italy
| | - Umberto Cariboni
- Thoracic Surgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alberto Testori
- Thoracic Surgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pierluigi Novellis
- Thoracic Surgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Edoardo Bottoni
- Thoracic Surgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Eliseo Passera
- Thoracic Surgery Department, Humanitas Gavazzeni, Bergamo, Italy
| | - Emanuela Morenghi
- Biostatistics Unit, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marco Alloisio
- Thoracic Surgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Science, Humanitas University, Rozzano, Milan, Italy
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Video-Assisted Thoracoscopic Versus Robotic-Assisted Thoracoscopic Thymectomy: Systematic Review and Meta-analysis. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 12:259-264. [PMID: 28759542 DOI: 10.1097/imi.0000000000000382] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Minimally invasive thoracic surgical procedures, performed with or without the assistance of a robot, have gained popularity over the last decade. They have increasingly become the choice of intervention for a number of thoracic surgical operations. Minimally invasive surgery decreases postoperative pain, hospital stay and leads to a faster recovery in comparison with conventional open methods. Minimally invasive techniques to perform a thymectomy include video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS). In this study, we aim to systematically review and interrogate the literature on minimally invasive thymectomy and draw a meta-analysis on the outcomes between the two approaches. METHODS An extensive electronic health database search was performed on all articles published from inception to May 2015 for studies describing outcomes in VATS and RATS thymectomy. RESULTS A total of 350 patients were included in this study, for which 182 and 168 patients underwent RATS and VATS thymectomy, respectively. There were no recorded in-hospital deaths for either procedure. There was no statistical difference in conversion to open, length of hospital stay, or postoperative pneumonia. Operational times for RATS thymectomy were longer. CONCLUSIONS The VATS and RATS thymectomy offer good and safe operative and perioperative outcomes. There is little difference between the two groups. However, there is poor evidence basis for the long-term outcomes in minimally invasive procedures for thymectomy. It is imperative that future studies evaluate oncological outcomes both short and long term as well as those related to safety.
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Kajiwara N, Kato Y, Hagiwara M, Kakihana M, Ohira T, Kawate N, Ikeda N. Cost-Benefit Performance Simulation of Robot-Assisted Thoracic Surgery As Required for Financial Viability under the 2016 Revised Reimbursement Paradigm of the Japanese National Health Insurance System. Ann Thorac Cardiovasc Surg 2018; 24:73-80. [PMID: 29343662 DOI: 10.5761/atcs.oa.17-00094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To discuss the cost-benefit performance (CBP) and establish a medical fee system for robotic-assisted thoracic surgery (RATS) under the Japanese National Health Insurance System (JNHIS), which is a system not yet firmly established. METHODS All management steps for RATS are identical, such as preoperative and postoperative management. This study examines the CBP based on medical fees of RATS under the JNHIS introduced in 2016. RESULTS Robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) now receive insurance reimbursement under the category of use of support devices for endoscopic surgery ($5420 and $3485, respectively). If the same standard amount were to be applied to RATS, institutions would need to perform at least 150 or 300 procedures thoracic operation per year to show a positive CBP ($317 per procedure as same of RALP and $130 per procedure as same of RAPN, respectively). CONCLUSION Robotic surgery in some areas receives insurance reimbursement for its "supportive" use for endoscopic surgery as for RALP and RAPN. However, at present, it is necessary to perform da Vinci Surgical System Si (dVSi) surgery at least 150-300 times in a year in a given institution to prevent a deficit in income.
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Affiliation(s)
- Naohiro Kajiwara
- Department of Surgery, Tokyo Medical University, Tokyo, Japan.,Department of Health Science and Social Welfare, Waseda University School of Human Sciences, Tokyo, Japan
| | - Yasufumi Kato
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masaru Hagiwara
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | | | - Tatsuo Ohira
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Norihiko Kawate
- Department of Health Science and Social Welfare, Waseda University School of Human Sciences, Tokyo, Japan
| | - Norihiko Ikeda
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
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Ricciardi S, Zirafa CC, Davini F, Melfi F. How to get the best from robotic thoracic surgery. J Thorac Dis 2018; 10:S947-S950. [PMID: 29744221 DOI: 10.21037/jtd.2018.03.157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The application of Robotic technology in thoracic surgery has become widespread in the last decades. Thanks to its advanced features, the robotic system allows to perform a broad range of complex operations safely and in a comfortable way, with valuable advantages related to low invasiveness. Regarding lung tumours, several studies have shown the benefits of robotic surgery including lower blood loss and improved lymph node removal when compared with other minimally invasive techniques. Moreover, the robotic instruments allow to reach deep and narrow spaces permitting safe and precise removal of tumours located in remote areas, such as retrosternal and posterior mediastinal spaces with outstanding postoperative and oncological results. One controversial finding about the application of robotic system is its high capital and running costs. For this reason, a limited number of centres worldwide are able to employ this groundbreaking technology and there are limited possibilities for the trainees to acquire the necessary skills in robotic surgery. Therefore, a training programme based on three steps of learning, associated with a solid surgical background and a consistent operating activity, are required to obtain effective results. Putting this highest technological innovation in the hand of expert surgeons we can assure safe and effective procedures getting the best from robotic thoracic surgery.
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Affiliation(s)
- Sara Ricciardi
- Unit of Thoracic Surgery, Robotic Multispeciality Center for Surgery, University Hospital of Pisa, Pisa, Italy
| | - Carmelina Cristina Zirafa
- Unit of Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispeciality Center for Surgery, University Hospital of Pisa, Pisa, Italy
| | - Federico Davini
- Unit of Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispeciality Center for Surgery, University Hospital of Pisa, Pisa, Italy
| | - Franca Melfi
- Unit of Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispeciality Center for Surgery, University Hospital of Pisa, Pisa, Italy
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Yin DT, Huang L, Han B, Chen X, Yin SM, Zhou W, Chu J, Liang T, Yun TY, Liu Y. Independent long-term result of robotic thymectomy for myasthenia gravis, a single center experience. J Thorac Dis 2018; 10:321-329. [PMID: 29600063 DOI: 10.21037/jtd.2017.12.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Robotic thymectomy has been suggested a feasible and safe approach for myasthenia gravis (MG). Few investigations have revealed the independent effect of robotic thymectomy without the confounding impact of immunosuppressive (IM) therapy. Methods Between May 2009 and December 2012, robotic extended thymectomy was carried out for patients with diagnosis of MG. The clinical data, subsequent neurological therapy and postintervention status were collected. Results Data of 37 cases was available for analysis. The mean follow-up was 70.0±13.3 months. The median age was 40 years. Twelve (32.4%) patients kept free of IM therapy, and 25 (67.6%) patients accepted postoperatively. The overall 5-year complete stable remission (CSR) rate was 40.6% and improvement rate was 81.6%. The young (age ≤40) displayed a significant better CSR rate (P=0.015) and a trend of better improvement rate (P=0.050) compared to the old (age >40). Patients without usage of IM therapy showed significant higher CSR rate (P=0.014) and improvement rate (P=0.024) compared to those with usage of IM therapy. Patients with Myasthenia Gravis Foundation of America (MGFA) classes I showed a trend of higher remission rate by multivariate analysis. No significant differences were found for the remission rate according to gender, pathology, and the duration of symptoms. Conclusions The mono-therapy of robotic thymectomy may bring with a satisfactory long-term result for part of MG patients. Precision selection and individualized therapy are of the most importance.
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Affiliation(s)
- Dong-Tao Yin
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China.,Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Ling Huang
- Department of Neurology, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Bing Han
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Xiu Chen
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Shi-Min Yin
- Department of Neurology, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Wen Zhou
- Department of Cadre's Ward, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Jian Chu
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Tao Liang
- Department of Thoracic Surgery, The General Hospital of the PLA Rocket Force, Beijing 100088, China
| | - Tian-Yang Yun
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China
| | - Yang Liu
- Department of Thoracic Surgery, The PLA General Hospital, Beijing 100853, China
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Batirel HF. Minimally invasive techniques in thymic surgery: a worldwide perspective. J Vis Surg 2018; 4:7. [PMID: 29445593 DOI: 10.21037/jovs.2017.12.18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 12/18/2017] [Indexed: 11/06/2022]
Abstract
Minimally invasive surgical techniques are important in surgical management of thymic pathologies. Traditional access techniques are being replaced with minimally invasive techniques using multiportal or uniportal approach. Adoption of minimally invasive techniques for thymic malignancies has been slow due to long term recurrence concerns. Recent studies show that minimally invasive video-assisted thoracoscopic surgery (VATS) or robotic approach to early stage thymic malignancies are associated with less intraoperative bleeding, lower rate of respiratory complications, shorter chest tube duration and shorter hospital stay. Oncologic outcomes are at least equivalent to open approach. Minimally invasive approach for benign pathologies is widely applied. There are significant variations in VATS approaches for thymus, showing a multinational interest in the issue of minimizing trauma during thymectomy. Use of robotic technology is also popular, as the retrosternal area is a narrow anatomic space to manipulate conventional instruments. The evolution of minimally invasive surgery for thymus has been possible with contribution from centers all around the world. In the current practice, various approaches are being adopted and every surgeon should prefer a technique depending on surgical preference and experience.
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Affiliation(s)
- Hasan Fevzi Batirel
- Department of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
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48
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Santini M, Fiorelli A. Surgery: Recommendations for Surgeons. CURRENT CLINICAL PATHOLOGY 2018:43-64. [DOI: 10.1007/978-3-319-90368-2_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Zieliński M, Rybak M, Solarczyk-Bombik K, Wilkojc M, Czajkowski W, Kosinski S, Fryzlewicz E, Nabialek T, Szolkowska M, Pankowski J. Subxiphoid uniportal VATS thymectomy. J Vis Surg 2017; 3:171. [PMID: 29302447 DOI: 10.21037/jovs.2017.09.13] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 09/25/2017] [Indexed: 11/06/2022]
Abstract
Background To present the technique of minimally invasive extended thymectomy performed through the uniportal subxiphoid approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). Methods Operative technique: the whole dissection was performed through the 4-7 cm transverse or longitudinal subxiphoid incision with use of videothoracoscope. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. Results There were four patients in the period 1.1.2017-30.4.2017. There was no mortality and morbidity. Conclusions The uniportal subxiphoid approach combined with double elevation of the sternum enabled very extensive thymectomy in case of thymoma.
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Affiliation(s)
- Marcin Zieliński
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | - Mariusz Rybak
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | | | - Michal Wilkojc
- Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
| | | | - Sylweriusz Kosinski
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | - Edward Fryzlewicz
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
| | - Tomasz Nabialek
- Department of Anaesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland
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Latif MJ, Park BJ. Robotics in general thoracic surgery procedures. J Vis Surg 2017; 3:44. [PMID: 29078607 DOI: 10.21037/jovs.2017.03.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 01/23/2017] [Indexed: 11/06/2022]
Abstract
The use of robotic technology in general thoracic surgical practice continues to expand across various institutions and at this point many major common thoracic surgical procedures have been successfully performed by general thoracic surgeons using the robotic technology. These procedures include lung resections, excision of mediastinal masses, esophagectomy and reconstruction for malignant and benign esophageal pathologies. The success of robotic technology can be attributed to highly magnified 3-D visualization, dexterity afforded by 7 degrees of freedom that allow difficult dissections in narrow fields and the ease of reproducibility once the initial set up and instruments become familiar to the surgeon. As the application of robotic technology trickle downs from major academic centers to community hospitals, it becomes imperative that its role, limitations, learning curve and financial impact are understood by the novice robotic surgeon. In this article, we share our experience as it relates to the setup, common pitfalls and long term results for more commonly performed robotic assisted lung and thymic resections using the 4 arm da Vinci Xi robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) to help guide those who are interested in adopting this technology.
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Affiliation(s)
- M Jawad Latif
- Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard J Park
- Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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